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ONSITE WASTEWATER TREATMENT SYSTEM PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 4 , C/IT�Y/ZIP 7 Q r <br /> CROSS STREET /� L1 (G� �� APN ()q l�?V j? PARCEL SIZE 1 �� /C�O p <br /> OWNER NAME /%/I/'D/ PHONE <br /> OWNER ADDRESS�jS <br /> C.� <br /> T / e�e_ /C917 CITY/STATE/ZIP <br /> /l <br /> CONTRACTOR - AA'6�('167�1h7•✓Lf%�e�GX/�• PHONE "L(A (C1�3 �f7 j <br /> CONTRACTOR ADDRESS � � �/ <br /> /�,4 , l CITY/STATE/ZIP J J�`, y a <br /> LICENSE 111-IC-42 ❑ <br /> 1-IC-42 CIC-36 OTHER_'/9 NUMBER �J �� EXPIRATION DATE Z21 �Z- Z <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: -i NEW INSTALLATION REPAIR/ADDITION i_ ENGINEER DESIGNED/ALTERNATIVE <br /> REPLACEMENT OUT-OF-SERVICE SEPTIC SYSTEM K DESTRUCTION S-fj2IIL 1 1G,ii k <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL ❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ PKG TX PLANT ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) <br /> ❑ LEACH LINES LEACHING CHAMBERS #of LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, <br /> STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> MINIA4UM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL 209 953-7697 <br /> SIGNED TITLE Gee/ DATE I <br /> r <br /> A UI <br /> Cm n..R'_A-rA <br /> E T <br /> / DEPARTMENT USE ONLY qq <br /> Application Accepted (By �J�G L— Date 0 10 do';L- Area % _/ Employee ID# D� <br /> Final Inspection By }1 . Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: 'Pit/S.Aip Soil Character: <br /> COMMENTSTIC1]7C'1^ ho %,orne, !?us beNrl gLc,nOreed ��Jyl �J��s h-c ed ij h wzi6je. Ylome <br /> Se 11C v`J ob/ ' . r/!S rle' o //IM fw e <br /> PE SC Received eck Amount Date Permit/ Invoice# Permit ID# <br /> Code INFO B ash Remitted Service Re uest# <br /> 1 p-7S #1q$D� lS� 121n�2o f <br /> 42-01 P t v` ( ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />